Facing a survey? Watch for more ‘A’ standards

These standards carry the entire weight of the score

The presence of fewer standards in the new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) manual — 280, compared to 386 in the last manual — means the weights of the standards have changed. If you are facing a survey this year, take note: "Some are weighted more heavily," says Maryanne Popovich, RN, MPH, director of home care accreditation services at JCAHO. However, that greater emphasis does not fall in any particular category. Rather, it is spread across the manual.

In addition, there are now 29 "A" standards — those deemed so important that they carry the entire weight of the score — compared with 27 under the previous regime, she says. The changes fall into the following three chapters.


The first change is in chapter two, which deals with assessment of patients. In the past, the emphasis on geriatric patients in home care has left patient assessment wanting in other categories, Popovich says. JCAHO added its first A standards to the chapter to combat this. Each deals with a category of specialty patients — one for interpartum patients, one on patients with behavioral problems, and one dealing with infants/children/adolescents. (See sample assessment form, p. 37.)

"You can’t take any of these patients and use the same assessment tools you use for your elderly clients," says Popovich. "We want you to make sure you have appropriate practices in place for all your patients."

Seek help from hospitals, universities

Betty Dixon, RN, a consultant in Savannah, GA, who works with Medical Management Development & Associates, says one place you can look to find that information is your local hospital. "It’s easier if you are attached to a hospital because you can use their tools and modify them to meet your needs."

But if you are a stand-alone agency and your hospital will not assist you, Dixon says you can find help from local nursing programs at universities or community colleges in your area, or even in some libraries. "You can find books of forms that apply and you can use them as a pattern," says Dixon. "But you have to do something that proves you know what to look for in every type of patient you see, even if you only see a couple children per year."

In Home Health, a national home care agency based in Minnetonka, MN, looked at supplementary assessment forms about six months ago, according to Susan Garner, RN, BSN, director of operations management. Garner says there was already a psychiatric assessment for patients with behavioral problems. When the new standards were released, she compared them to the existing form. "I found they were looking for a lot more specific information," she recalls. For example, the commission wanted more information included on the social, cultural, and religious environment of patients. The additions made sense. "If you have a psych patient, then social things can affect behavior. If we have to address both personal and family issues, then our care plan is going to be different."

After Garner made the changes, she sent the new form out to field staff for comment. Their criticisms were then incorporated into a final version. She followed the same process for children. "In that case, we ended up including more information on the developmental stage of the child and immunization standards."

For interpartum patients, however, In Home Health turned to a consultant. "The person who had developed the program had left the company," says Garner. "We went back to that person to make sure that the assessment was appropriate."

Improving Organizational Performance.

Chapter six also had no A standards last year, says Popovich. But JCAHO is adamant about having proof that your organization "systematically improves performance." Popovich says just saying you have some sort of performance or quality improvement program won’t be enough any longer. "You have to show us," she says.

In Home Health has created performance improvement committees at each of its 43 branches, says Garner. Each committee chooses three areas on which to concentrate its improvement efforts. They look at national standards relating to those issues, she says. One branch may decide to concentrate on cutting rehospitalization rates. They have national data with which to compare themselves, set a plan, and monitor it monthly. "It is very analytical," she says. The branch can then provide the Joint Commission with charts and graphs that prove its performance improvement program is more than a piece of paper.

To ensure that branches choose relevant issues on which to concentrate, Garner says a corporate performance improvement committee chooses about six branches per quarter and reviews their plans. "But we don’t really have a problem," she says. "The branches are very interested in tracking their performance and excited about monitoring their progress. They also have demonstrated a good understanding of what issues affect them and are appropriate for study."

Management of Information.

This is perhaps the most startling change in the manual. Where there were two A standards in the previous version, there are none this year, says Popovich. "We wanted to make sure the emphasis is on work processes, not documents," she explains. "Anyone can have a system on paper, but that doesn’t mean it works. You can show me a faultless plan and perfect documentation, but how do I know it really works?"

Popovich says it is too early to get any feedback on changes from the surveys that have occurred thus far this year. Preliminary data should be compiled in April. Meanwhile, the dozen seminars she has given on the new manual since its introduction last fall have made her hopeful that the changes will go over well. "I have seen universal acceptance of the standards and the changes," she says. "But we won’t know for a while how people are scoring."

She does have some advice for people facing surveys. "Year in and year out we find problems with the same areas," she says. "Organizations have trouble complying with the care planning process, proving the competency of their staff, monitoring their patients — particularly in relation to medication regimes — improving the overall performance of their organization, and getting proper physicians’ orders when they are required. The same issues continue to arise."